Multi-level Intervention to increase participation in mammography screening: ¡Fortaleza Latina! study design

BackgroundBreast cancer is the most common cancer and the leading cause of death among Latinas in the United States. The Multi-level Intervention to Increase Participation in Mammography Screening study (¡Fortaleza Latina!) is a partnership among research institutions, a Latino-serving community-based primary care clinic organization, and a cancer treatment center. The study will assess the efficacy of a clinic- and patient-level program to increase breast cancer screening among Latinas in Western Washington.Methods/designThe intervention is a multi-level breast cancer screening program in four participating primary care clinics. The study is a parallel randomized controlled trial of 600 Latino women aged 42–74 who are non-compliant with breast cancer screening guidelines. Participants will be randomized within clinic using block randomization to: (1) a control arm (usual care); and (2) a theory-based counseling program consisting of a ‘promotora’ or community health worker-led home-based intervention to encourage breast cancer screening. At the clinic-level, two clinics will offer additional mammography services provided by a mobile mammography unit operated by the Seattle Cancer Care Alliance. The primary endpoint is the rate of mammography uptake over the 1-year follow-up period.DiscussionThis multi-level intervention aims to raise rates of participation in breast cancer screening among Latino women. If effective, the program may improve rates of early detection of breast cancer in Latino women.Clinicaltrials.gov Registration Number: NCT02010008.     

Chinese women's motivation to receive future screening: The role of social-demographic factors,knowledge and risk perception of cervical cancer

Purpose of the researchThis paper adopted Protection Motivation Theory (PMT) to examine Chinese women's knowledge and perceptions of cervical cancer risk and factors influencing their motivation to receive future screening.Methods and sampleA cross-sectional survey was conducted with 167 Chinese women (142 women were willing to receive a screening in the future and 25 women were not) in 2007 to collect women's socio-demographic information and sexual history, perceptions related to body health and knowledge about cervical cancer and screening, and Protection Motivation Theory measures.Key resultsThe majority of women stated they intended to receive future screening and response efficacy was significantly associated with their intention. However, no significant association was observed between sexual history and protection motivation. Using multivariate analysis, cancer in relatives (odds ratio, OR = 9.97, 95% CI [1.44–436.3], p = 0.010), a perception that visiting a doctor regularly is important to health (OR = 9.85, 95% CI [1.61–999.9], p = 0.009)), and ever attending for cervical screening during the previous three years (OR = 3.49, 95% CI [1.23–11.02], p = 0.016) were significantly associated with women' motivation to receive future screening.ConclusionThe findings of this study highlight the important role of women's beliefs in the value of cervical screening and previous screening experience in motivating them to receive a screening. Education intervention is needed to provide information and raise public awareness about the importance of cervical screening to women's health. Culture-related beliefs and social motivational processes in addition to those specified by PMT need to be addressed.     

A web-based personalized risk communication and decision-making tool for women with dense breasts: Design and methods of a randomized controlled trial within an integrated health care system

BackgroundMammographic breast density is one of the strongest risk factors for breast cancer after age and family history. Mandatory breast density disclosure policies are increasing nationally without clear guidance on how to communicate density status to women. Coupling density disclosure with personalized risk counseling and decision support through a web-based tool may be an effective way to allow women to make informed, values-consistent risk management decisions without increasing distress.Methods/designThis paper describes the design and methods of Engaged, a prospective, randomized controlled trial examining the effect of online personalized risk counseling and decision support on risk management decisions in women with dense breasts and increased breast cancer risk. The trial is embedded in a large integrated health care system in the Pacific Northwest. A total of 1250 female health plan members aged 40–69 with a recent negative screening mammogram who are at increased risk for interval cancer based on their 5-year breast cancer risk and BI-RADS® breast density will be randomly assigned to access either a personalized web-based counseling and decision support tool or standard educational content. Primary outcomes will be assessed using electronic health record data (i.e., chemoprevention and breast MRI utilization) and telephone surveys (i.e., distress) at baseline, six weeks, and twelve months.DiscussionEngaged will provide evidence about whether a web-based personalized risk counseling and decision support tool is an effective method for communicating with women about breast density and risk management. An effective intervention could be disseminated with minimal clinical burden to align with density disclosure mandates.Clinical Trials Registration Number: NCT03029286.     

Translating research into practice: Protocol for a community-engaged,stepped wedge randomized trial to reduce disparities in breast cancer treatment through a regional patient navigation collaborative

BackgroundRacial and socioeconomic disparities in breast cancer mortality persist. In Boston, MA, Black, Non-Hispanic women and Medicaid-insured individuals are 2–3 times more likely to have delays in treatment compared to White or privately insured women. While evidence-based care coordination strategies for reducing delays exist, they are not systematically implemented across healthcare settings.MethodsTranslating Research Into Practice (TRIP) utilizes community engaged research methods to address breast cancer care delivery disparities. Four Massachusetts Clinical and Translational Science Institute (CTSI) hubs collaborated with the Boston Breast Cancer Equity Coalition (The Coalition) to implement an evidence-based care coordination intervention for Boston residents at risk for delays in breast cancer care. The Coalition used a community-driven process to define the problem of care delivery disparities, identify the target population, and develop a rigorous pragmatic approach. We chose a cluster-randomized, stepped-wedge hybrid type I effectiveness-implementation study design. The intervention implements three evidence-based strategies: patient navigation services, a shared patient registry for use across academic medical centers, and a web-based social determinants of health platform to identify and address barriers to care. Primary clinical outcomes include time to first treatment and receipt of guideline-concordant treatment, which are captured through electronic health records abstraction. We will use mixed methods to collect the secondary implementation outcomes of acceptability, adoption/penetration, fidelity, sustainability and cost.ConclusionTRIP utilizes an innovative community-driven research strategy, focused on interdisciplinary collaborations, to design and implement a translational science study that aims to more efficiently integrate proven health services interventions into clinical practice.     

Understanding the cervical screening behaviour of Chinese women: The role of health care system and health professions

BackgroundIn China, cervical cancer cases are increasing, making an impact on the worldwide burden of cervical cancer. Despite the initiatives undertaken by the Chinese government, the current coverage of cervical screening in China remains suboptimal. There is an urgent need to identify the facilitators and barriers associated with the uptake of cervical cancer screening among the Chinese population.PurposeThe study aimed to explore the experiences and perceptions of cervical cancer screening of mainland Chinese women in relation to their screening behaviour, particularly in the aspects of health care system and health profession roles.MethodsA qualitative research was conducted using semi-structured interviews. A total of 27 Chinese women aged 25 to 50 (both screened and non-screened women) completed the interviews. The analysis of the interview data was undertaken inductively using latent content analysis.Discussion and conclusionResults showed that organised health examination programmes provide a good basis for integrating cervical screening into broader checks on the health of women, and utilising different networks of social support facilitate the utilisation of the screening service. However, education on cervical cancer and screening must be made more generally available. More importantly, there is a need for a more participatory and empowering exchange in the encounter between health professions and these women. Appropriate training program is strongly recommended for health professions about communicate skills with patients. Future work should focus on identifying strategies to overcome the barriers to cervical screening related to health care system and medical professions among this population.     

Older women with breast cancer: perceptions of the effectiveness of nurse case managers

BACKGROUND: There are many challenges that an older woman and her family face when diagnosed with breast cancer. Utilizing community-based nurse case managers may influence the older client and her family to adapt to the many challenges associated with the diagnosis and treatment of breast cancer. PURPOSE: The purpose of this qualitative study is to describe how older breast cancer clients perceive community-based nurse case managers. From findings generated, recommendations were developed to improve the practice of community-based nurse case managers. METHOD: A randomized prospective trial to evaluate the effect of nurse case management on the treatment of 106 older women with breast cancer provided data for this content analysis. Older women (>65 years of age) newly diagnosed with breast cancer cared for by 60 surgeons practicing at 13 community and 2 public hospitals in southeast Texas were invited to participate. DISCUSSION: Community-based nurse case managers made a positive impact on older women with breast cancer by helping in managing coexisting medical conditions, providing support, providing education, giving assistance with activities of daily living (ADLs), and helping to navigate through the health care system. To increase their effectiveness, it was recommended that nurse case managers communicate well, be well educated about breast cancer, have standard gerontology nurse case management training, and integrate multiple support systems when caring for older clients with breast cancer. CONCLUSION: There are unique challenges that an older woman and her family face when diagnosed with breast cancer. Utilizing community-based nurse case managers may influence the client and her family to adapt to the many challenges associated with the diagnosis and treatment of breast cancer. Community-based nurse case managers can make a positive difference on the outcomes of older women with breast cancer.     

Older African American women's beliefs, attitudes, and behaviors about breast cancer

Breast cancer poses a greater risk for African American than Caucasian women due to persistent health disparities. To reduce mortality risk, culturally specific knowledge is needed to support and encourage regular breast cancer screening and risk-reduction behaviors in older African American women. The specific aims of this study were to identify social, cultural, and behavioral factors associated with regular participation in breast cancer screening and risk-reduction behaviors; examine health beliefs that may influence regular participation in breast cancer screening and risk-reduction behaviors; and identify perceived facilitators and barriers to regular breast cancer screening and risk-reduction behaviors. African American women older than 65 (N = 57) participated in six focus groups. Analysis of focus group data revealed six major themes: Being Blessed, Cancer as a Death Sentence, Fear/Fear of Disfigurement, Avoiding Finding Out, Beliefs About Breast Cancer, and Tending to One's Family. These themes could be used by health care providers to develop culturally relevant educational initiatives to promote breast health practices and risk-reduction behaviors in this vulnerable population, thus helping reduce breast cancer disparities.     

Compliance with Recommended Cancer Screening among Emergency Department Patients: A Multicenter Survey

Objectives: The objectives were to measure compliance with, and possible sociodemographic disparities for, cancer screening among emergency department (ED) patients. Methods: This was a cross‐sectional survey in three academic EDs in Boston. The authors enrolled consecutive adult patients during two 24‐hour periods at each site. Self‐reported compliance with standard recommendations for cervical, breast, testicular, and prostate cancer screening were measured. The chi‐square test was used test to evaluate associations between demographic variables and cancer screening compliance. Results: The authors enrolled 387 patients (81% of those eligible). The participants had a mean (±standard deviation) age of 44 (±18) years and were 52% female, 16% Hispanic, and 65% white. Sixty‐seven percent (95% confidence interval [CI] = 60% to 73%) of all women reported Pap smear examinations in the past 3 years, 92% (95% CI = 85% to 96%) of women aged ≥40 years reported clinical breast examinations, and 88% (95% CI = 81% to 94%) of women aged ≥40 years reported mammography. Fifty‐one percent (95% CI = 40% to 61%) of men aged 18–39 years reported testicular self‐examinations, and among men aged ≥40 years, 79% (95% CI = 69% to 87%) reported digital rectal examinations (DREs) and 51% (95% CI = 40% to 61%) reported prostate‐specific antigen (PSA) testing. Racial and ethnic minorities reported slightly lower rates of clinical breast examinations and testicular self‐examinations. Conclusions: Most women and a majority of men in our ED‐based study were compliant with recommended measures of cervical, breast, testicular, and prostate cancer screening. No large sociodemographic disparities in our patient population were identified. Based on these data, and the many other pressing public health needs of our ED population, the authors would be reluctant to promote ED‐based cancer screening initiatives at this time.     

The Faith,Activity, and Nutrition (FAN) Program: Design of a participatory research intervention to increase physical activity and improve dietary habits in African American churches

BackgroundAfrican Americans are at increased risk for cardiovascular disease and cancer morbidity and mortality. Physical activity and healthy dietary practices can reduce this risk. The church is a promising setting to address health disparities, and community-based participatory research is a preferred approach.ObjectivesUsing a community-based participatory approach and the social ecologic model, the FAN trial aims to increase self-reported moderate-intensity physical activity and fruit and vegetable consumption and reduce blood pressure in African American church members. Secondary aims are to increase objectively measured moderate-intensity physical activity and fiber/whole grain consumption and reduce fat consumption.DesignFAN is a group randomized trial (GRT) with two levels of clustering: participants (N = 1279; n = 316 accelerometer subgroup) within church and church within church cluster. In the first wave, seven clusters including 23 churches were randomized to an immediate intervention or delayed intervention. In subsequent waves, 51 churches were randomized to an immediate or delayed intervention.MethodsChurch committee members, pastors, and cooks participate in full-day trainings to learn how to implement physical activity and dietary changes in the church. Monthly mailings and technical assistance calls are delivered over the 15-month intervention. Members complete measurements at baseline and 15 months. A detailed process evaluation is included.SummaryFAN focuses on modifying the social, cultural, and policy environment in a faith-based setting. The use of a community-based participatory research approach, engagement of church leaders, inclusion of a detailed process evaluation, and a formal plan for sustainability and dissemination make FAN unique.     

Effect of Psycho-Educational Intervention to Reduce Anxiety and Depression at Postintervention and Follow-Up in Women with Breast Cancer: A Systematic Review and Meta-Analysis

ObjectivesTo examine the effectiveness of the psycho-educational intervention in reducing anxiety and depressive symptoms for women with breast cancer in post- and follow-up status.Data SourcesA systematic search of 16 electronic databases to identify all randomized controlled trial studies that examine the effects of psycho-education on anxiety and depression among women with breast cancer. The standardized mean differences (SMDs) between groups in depression and anxiety levels for postintervention and follow-up were computed for each study.ConclusionEvidence suggests that psycho-educational intervention effectively relieves anxiety and depressive symptoms among women with breast cancer postintervention and follow-up.Implications for PracticeA significant effect of the psycho-education intervention was found to reduce anxiety and depressive symptoms in women with breast cancer. Such service was recommended in nursing practice.     

Barriers to effective uptake of cancer screening among Black and minority ethnic groups

AIM: To describe some of the factors that act as barriers to effective uptake of breast and cervical cancer screening services among black minority ethnic (BME) groups living in Brent and Harrow in the UK. DESIGN: A series of focus groups among African Caribbean, African, Gujarati, Pakistani, Greek and Arabic groups were held to discover their perceptions of cancer screening, the barriers to effective uptake and some strategies for intervention. SAMPLE: This consisted of 135 participants: 85 women and 50 men. RESULTS: Analysis of focus group data has revealed poor knowledge, underlying health and cultural beliefs, attitudes, language and unhelpful attitudes of health professionals to be important barriers. In terms of strategies for effective intervention, the most popular strategy for improving uptake of screening services was community-based cancer awareness education that is sensitive to religious and cultural needs. CONCLUSION: There is a need to provide community-based education to increase the uptake of screening services among BME groups. It is essential to plan concurrently to educate GPs and other health professionals in cultural beliefs and customs, language needs, racial awareness and communication skills.     

Psychometric properties of the Chinese Breast Cancer Screening Beliefs questionnaire

BackgroundBreast cancer is the most common type of cancer in women. The Chinese Breast Cancer Screening Beliefs (CBCSB) questionnaire was developed to measure Chinese–Australian women’s beliefs, knowledge and attitudes about breast cancer and breast cancer screening.PurposeTo assess the psychometrics of the modified version CBCSB in a Chinese-speaking community.MethodsTwo items in the original CBCSB were removed because they were not applicable to the Hong Kong setting, which resulted in an 11-item CBCSB. A total of 730 women aged at least 18 years old without a history of breast cancer self-completed the questionnaire.ResultsBased on 730 Chinese-speaking women with mean age of 43 years, the three hypothesized subscales of the CBCSB had Cronbach’s alpha ranging between 0.69 and 0.75. Non-responses to the items were at most only 3.3%. The corrected item-total correlations for the hypothesized subscales ranged from 0.35 to 0.63 and were higher than those for the competing subscales. As hypothesized, the frequency of health practices was significantly associated with all subscales of the CBCSB. Confirmatory factor analysis showed an adequate fit for the hypothesized three-factor structure of the modified CBCSB questionnaire.ConclusionsThe 11-item CBCSB questionnaire was culturally appropriate, reliable and valid in a Chinese-speaking community setting. It can be used to gain understanding of Chinese-speaking women’s beliefs, knowledge and attitudes about breast cancer and breast cancer screening. It may also serve as an outcome for the development and assessment of public education programs for breast cancer screening.     

Role of cervical cancer screening during prenatal checkups for infectious diseases: A retrospective,descriptive study

ObjectiveThis study was conducted to evaluate the status and role of cervical cytology affected by human papillomavirus infection and other infectious diseases screened during routine prenatal checkups.MethodsWe retrospectively examined medical records containing the screening results for infectious diseases and cervical cancer in women who delivered neonates in our hospital from 2014 to 2017.ResultsAmong 3393 deliveries, 18.8% of women underwent a regular cervical cancer screening within 1 year of becoming pregnant, and 2641 women underwent a cervical cytology screening during this pregnancy. The cytological diagnostic results showed that 2562 women (97.0%) were negative for intraepithelial lesions or malignancy, whereas 79 (3.0%) had abnormal results. Of those with abnormal cytology results, 70 had abnormal cytology that was newly detected in this pregnancy, and 42 had grade ≥1 cervical intraepithelial neoplasia lesions. Spatulas were the most frequently used cytological sampling instruments, followed by cotton swabs. Cervical cytology revealed no major adverse reactions during these pregnancies.ConclusionsOur results confirm the importance of screening for infectious diseases during pregnancy. Only 20% of the women underwent a regular pre-pregnancy cervical cytology screening. Cervical cytology screening during pregnancy may currently be playing a crucial role in preventing cervical cancer in Japan.     

The Mexican-American Trial of Community Health workers (MATCH): design and baseline characteristics of a randomized controlled trial testing a culturally tailored community diabetes self-management intervention

ObjectivesCommunity Health Workers (CHWs) have been recommended to reduce diabetes disparities, but few robust trials of this approach have been conducted. Limitations of prior studies include: unspecified a priori outcomes; lack of blinded outcome assessments; high participant attrition rates; and lack of attention to intervention fidelity. These limitations reflect challenges in balancing methodologic rigor with the needs of vulnerable populations. The Mexican-American Trial of Community Health workers (MATCH) was a blinded randomized controlled trial testing CHW efficacy in improving physiologic outcomes and self-management behaviors among Mexican-Americans with type 2 diabetes. This paper describes methods used to overcome limitations of prior studies.Research design and methodsThe primary aim was to determine if a CHW intervention would result in significant reductions in Hemoglobin A1c and rates of uncontrolled blood pressure. 144 Mexican-Americans with diabetes were randomized. The intervention consisted of self-management training delivered by CHWs over a 24-month period; the comparison population received identical information via bilingual newsletter. Blinded research assistants completed assessments at baseline, 12 months, and 24 months post-randomization.ResultsThe MATCH cohort was characterized by low acculturation and socioeconomic status. Study participants had low rates of medication adherence and glucose monitoring. 70% had poor glycemic control with A1c levels over 7.0, and 57.3% had blood pressures worse than ADA target levels (< 130/80).ConclusionsMATCH preserved community sensitivity and methodologic rigor. The study's attention to intervention fidelity, behavioral attention control, blinded outcomes assessment, and strategies to enhance participant retention can be replicated by researchers testing culturally-tailored CHW interventions.     

Nursing clinical trial of breast self-examination education in China

LIU C.-Y., XIA H.-O., ISAMAN D.M., DENG W. & OAKLEY D. (2010) Nursing clinical trial of breast self-examination education in China. International Nursing Review 57 , 128–134
Aim:  The aim of this study was to test community-based nursing education about breast self-examination to see whether self-examination frequency could be increased.
Background:  Breast cancer rates in China are rising rapidly, especially in cities. The majority of Chinese women does not know about breast self-examination, and the Chinese health care system cannot provide mammograms for the millions of at-risk women throughout China.
Method:  This study was a randomized clinical trial of nurse-provided, community-based teaching of breast self-examination in the urban and rural areas of Tianjin and urban and suburban areas of Shanghai. Women ( n  = 1510) never diagnosed with breast cancer and 40 years and older were randomized by community and stratified by urban vs. other residences.
Results:  At baseline, 9% of the intervention and 6% of the control groups did breast self-examination at least every other month. After 12 months, 34% of the intervention, but only 11% of the control, group did breast self-examination that often ( P  < 0.001). There was a significant impact in urban, suburban and rural areas, and intervention effects were stronger than any of the other influences tested.
Conclusion:  The clinical trial showed a statistically significant increase in breast self-examination after the nursing education intervention. As no other breast cancer screening method is available in most of China, this method is best suited for the masses of people currently at risk in China.